Outcomes in Pediatric Traumatic Brain Injury Pediatric Rehabilitation Medicine Review epidemiology Objectives Describe normal brain development in context of TBI Discuss physical, cognitive and behavioral outcomes following pediatric TBI Briefly discuss predictors of outcome after TBI 1
Epidemiology Leading cause of death and disability in U.S. children (> 1 year of age) and adolescents 0-4 age group 216,000 ED visits 18,000 hospitalizations 1,035 deaths 5-14 age group 18,800 ED visits 24,000 hospitalizations 1,250 deaths Epidemiology Image from www.cdc.gov 2
Epidemiology Image from www.cdc.gov Epidemiology Image from www.cdc.gov 3
Epidemiology Image from www.cdc.gov Epidemiology 1.7 million civilian American TBI s/year ½ of these are in children < 15 years of age Estimated 145,000 children with TBI-related disability in the U.S. in 2005 Overall total life costs of injuries for children < 14 years of age $60.4 billion 4
Normal Development Age-Dependent Brain Changes 5
Dynamic Nature of Pruning The Human Brain Connectome 6
Guess the Deficit? Recovery is Complex 7
Implications of Plasticity Apoptosis of neurons Part of normal brain development Contribute to poorer outcomes? Review epidemiology Objectives Describe normal brain development in context of TBI Discuss physical, cognitive and behavioral outcomes following pediatric TBI Briefly discuss predictors of outcome after TBI 8
Long-term Outcome in Severe TBI Prospective review of severe pediatric TBI at Riley Hospital for Children (Indianapolis) Initial GCS 3-4 1988-2004 67 patients in database of 1636patients (4.1%) Long-term Outcome in Severe TBI 9
Long-term Outcome in Severe TBI Long-term Outcome in Severe TBI 10
Long-term Outcome in Severe TBI Long-term Outcome in Severe TBI 11
Long-term Outcome in Mod-Severe TBI Prospective study Pediatric unit in rehabilitation hospital 101 consecutive patients admitted between 2000-2005 Israel 77 children with moderate to severe TBI Followed for average of 10 years Long-term Outcome in Mod-Severe TBI 12
Long-term Outcome in Mod-Severe TBI Functional outcome at discharge 89.6% independent self-feeders 88.3% independent self-mobility Vegetative state (15) 93.8% conscious at discharge Long-term Outcome in Mod-Severe TBI Educational status at discharge 53 (68.9%) reintegrated into regular educational system 10 (13%) reintegrated into regular educational system with assistance 9 (11.7%) enrolled in special education 13
Long-term Outcome in Mod-Severe TBI Educational status at discharge 15 of 77 (19.5%) unable to reintegrate into educational system 9 (11.7%) needed further outpatient rehabilitative intervention 4 of these 9 at follow-up working or attending college 6 (7.8%) considered being unable to attend any form of educational service Long-term Outcome in Mod-Severe TBI Long-term follow up (phone interview) 57 > 18 years of age 31 (54.4%) employed (civilian or military) 29 maintained same working place > 1 year 23 (40.4%) unemployed 2 (3.5%) worked in protected environment 1 (1.8%) still in special education 14
Long-term Outcome in Mod-Severe TBI Long-term follow up (phone interview) 20 < 18 years of age 14 attended regular education system 3 required assistance 6 enrolled in special education Long-term Outcome in Mod-Severe TBI Positive outcome (61%) Enrollment in regular school or higher education Working Living independent Negative outcome (39%) Special education Unemployment Living with parents (if > 18 yrs) Living in protected housing 15
Long-term Outcome in Mod-Severe TBI Predictive Factors Positive Outcome Negative Outcome GCS (3-4) 21.3% 44.8% 0.029 Vegetative state at admission 12.8% 33.3% 0.031 Associated anoxic BI 4.3% 23.3% 0.015 Duration of unconsciousness 11 29 0.009 Duration of acute hosp. 23.1 38.5 0.015 Duration of rehab. (months) 5 8.4 0.009 IQ at d/c from rehab 98.7 79.5 <0.001 FIM at d/c from rehab Total 119.1 96.8 0.005 Motor 88 71.7 0.007 Cognitive 31.1 25.1 0.003 p Externalizing Behavior Externalizing behavior Negative behaviors directed toward external environment Decreased inhibition Poor anticipation of consequences Reduced cognitive empathy 16
Externalizing Behavior Longitudinal prospective study 55 young adults admitted to ED with history of TBI from 1993-1997 Mean age 23.85 years Injury age 1-12 years of age Externalizing Behavior 25% demonstrated clinical or subclinical threshold levels of externalizing behavior Associated with Poorer preinjury adaptive functioning Lower full-scale IQ More frequent pragmatic communication difficulty 17
Review epidemiology Objectives Describe normal brain development in context of TBI Discuss physical, cognitive and behavioral outcomes following pediatric TBI Briefly discuss predictors of outcome after TBI Early MRI Lesion Location and Volume Retrospective analysis of prospectively collected data Parkland Memorial Hospital and Children Medical Center Dallas 2005-2012 Ages 0-17 years Accidental TBI GCS < 12 Excluded if MRI evidence of hypoxic-ischemic injury 18
Early MRI Lesion Location and Volume FLAIR lesion volume Hyperintensity lesion volume index (HLVI) Zone A: cortical structures Zone B: basal ganglia, corpus callosum, internal capsule, thalamus Zone C: brainstem Lesion abnormalities correlated to GOS-E Pediatrics Early MRI Lesion Location and Volume 19
Early MRI Lesion Location and Volume Summary Pediatric TBI is the leading cause of death and disability in U.S. children > 1 year of age Most often due to MVC, especially in ages 5-24 years Non-accidental trauma not rare in ages 0-4 years Unsure exactly how neural plasticity plays a role 20
Summary Sparse (but growing) data re: long-term outcomes after pediatric TBI Generally, there are often long-term sequelae (functional, cognitive and behavioral), especially in children with severe TBI Questions? 21
References Popernack M.L., Gray N., and Reuter-Rice K. Moderate-to-severe traumatic brain injury in children: complications and rehabilitation strategies. J Pediatr Health Care. 2015 May-June;29(3):e1-7. Wilde E.A., Hunter J.V., and Bigler E.D. Pediatric traumatic brain injury: neuroimaging and neurorehabilitation outcome. NeuroRehabilitation. 2012; 31(3): 245-60. Fulkerson D.H., White I.K., Rees J.M., et al. Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4. J Neurosurg Pediatr. 2015;16:410-9. Shaklai S., Peretz R., Spasser R., Simantov M., and Groswasser Z. Long-term functional outcome after moderate-to-severe paediatric traumatic brain injury. Brain Inj. 2014;28(7):915-21. Ryan N.P., Hughes N., Godfrey C., Rosema S., Catroppa C., Anderson V.A. Prevalence and predictors of externalizing behavior in young adult survivors of pediatric traumatic brain injury. J Head Trauma Rehabil. 2015;30(2):75-85. Smitherman E., Hernandez A., Stavinoha P.L., Huang R., Kernie S.G., Diaz-Arrastia R., Miles D.K. Predicting outcome after pediatric traumatic brain injury by early magnetic resonance imaging lesion location and volume. J Neurotrama. 2015;32:1-14. 22